A voice from the edge

Madness is frightening, fascinating and something of which the mad are often deeply ashamed. It is thus special when a brilliant professor of psychiatry (at Johns Hopkins University) describes her own experience of manic depressive illness.

Her father was a military scientist, though clearly with a depressive character, and she grew up as a happy and successful student. But there were early signs that she had a rather special character: at 14 she refused to learn curtseying. Sheep, she thought. Then she had her first attack. She rushed about "like a crazed weasel, bubbling with plans and enthusiasms I staying up all night I reading everything that wasn't nailed down, filling manuscript books with poems" and making unrealistic plans about the future. She felt really great with a mind absolutely clear and finely focused. Everything made perfect sense and she was in a state of enchantment with the world. She buttonholed friends to tell them how wonderful it all was.

It was an intoxicating experience that was to recur with variations for many years to come. On future occasions she would, for example, spend money wildly and once bought "20 sundry Penguin books because I thought it would be nice if the penguins could form a colony". The other side of the illness was deep depression when nothing made sense.

Initially she thought she ought to be able to handle her own illness. Also, because everyone else was seeing a psychiatrist, she "naturally bought a horse". When she finally sought help she was, like so many others, deeply embarrassed. She started a long relationship with lithium, breaking it off on numerous occasions. She lived a tidal experience, flowing between mania and depression. Sometimes the mania was so destabilising that she determined to kill herself. At last she realised that "she could not imagine leading a normal life without taking lithium and having had the benefits of psychotherapy". Her early resistance was truly mad.

Her writing is so brilliant and her charm so seductive that at times it is hard to keep being aware how ill she was. Her relationships with lovers, husband, family and friends are beautifully described. One can almost feel her pain when she describes how, though lithium has saved her, she has had to give up those experiences that "were incredible and beautiful and took my breath away".

But one wants more, quite a lot more. From a talented psychiatrist one wants to get some insight into the nature of manic depressive illness. Do they really have virtually no understanding whatsoever, and if they do why are we not told? It is not enough to be told that it has a genetic basis. And why does lithium work so well and also how was it discovered to be a valuable treatment? Taking lithium, which is a first cousin to sodium, can hardly be a common occurrence. Then there is her praise of psychotherapy, which she says helped save her life. She had numerous sessions but there is not a clue as to what occurred during them; what approaches were used and why did they help her? Did any of her psychotherapists use cognitive therapy that has been so successful in treating depression? And, finally, it remains a puzzle as to how, with all that madness, she managed to continue to do her work and keep her job. One can only assume her brilliance, wit, good looks, intelligence and competence kept her afloat. But one would have liked to know. Even so, her book is essential and pleasurable reading for anyone with the faintest interest in manic depression.

Lewis Wolpert is professor of biology as applied to medicine, University College London.